TBL in Medical Education
Getting Beyond Covering Content
Small Group Learning in a Large Group
Setting
Edward E. McKee Central Michigan University College of Medicine
With Slides from Sandra Cook,
, Dean Parmelee
And Ruth Levine, UTMB.
Case #1
A 24 year old medical student presents with a
complaint of feeling overwhelmed in preparation for
an exam in three days, feels isolated from peers
(all of whom study individually), finds lectures boring,
and small groups not helpful except when the
“answers” are given right away.
Case #2
A 46 year old associate
professor of medicine
presents with complaint of
exasperation in teaching
clinical pharmacology
because the students,
though bright enough, never
seem to come prepared and
ready to be challenged.
Case #3
A 51 year old professor and course
director complains of fatigue from
having to beg clinical faculty to teach
small groups. She develops
migraine when they either fail to
show up or fail to follow the script for
what to teach. Some even give their
groups answers to exam questions!
Case #4
A “39” year old associate dean for med ed presents
with complaint of too many complaints from faculty
about students not coming to lecture and not being
prepared for small group discussions. Even she feels
that this ‘millennial generation’ wants to be spoon-fed
and that many of the faculty have given up trying to
become inspiring teachers.
TRADITIONAL
Wishful Thinking:
Before
During
Pre-work
Active
Learning
After
Homework
Exam
REALITY:
Before
Pre-work
During
Passive Lecture
After
Study
Exam
Traditional Reality:
Before
During
After
Video-taped
Team
Lecture Problem
Pre-work
Lecture/Text/
Solving
PowerPoint
Review
Study
First Need to Form Teams…
Principle: When forming teams, you want to
ensure equal distribution of resources and
maximize participation of all members
Operationalized:
Aim to identify important resources available to
individuals and equally distribute those
individuals
The teacher forms the teams – not students
5-7 individuals per team
R. Levine
Components of TBL
Sequence of Learning
R. Levine
IUSM-SB Genetics Module:
To Adequately Prepare for this TBL Session you
must:
 Read the lecture notes pages 51 – 69 and 87-91..
 View the Lecture recording (Camtasia ) online for
Lectures 2 and 3 (Mendelian Inheritance and
Population Genetics) ; or,
 View PowerPoints 2-3 on Mendelian Inheritance.and
Population Genetics
Reference in Genetics in Medicine 7th ED. Chapter 7,
and Pages 192-199.
IUSM-SB Genetics Module: Objectives
1. To explain the modes of inheritance of the most common genetic diseases.
2. To be able to write and interpret pedigree information from a patient
history and to determine the most likely mode of inheritance.
3. To be able to calculate carrier frequency and allele frequency in defined
populations given the incidence of an inherited disorder in that
defined population.
4. To be able to integrate pedigree risk and population risk in calculating
overall risk to any member of a pedigree.
5. To be able to identify and demonstrate when and how to use conditional
probability in a risk calculation.
6. To demonstrate the role of fitness and selection in determining the
likelihood of new mutations for a particular disorder.
7. To be able to use the Binomial theorem to calculate multiple probabilities
in families. For example what is the probability that a heterozygous
couple for Cystic Fibrosis alleles will have 2 affected children in a
family of 5 children?
Components of TBL
GRAT
Sequence of Learning
IRAT
R. Levine
IRAT



Basic questions to:
1.
Determine individual preparedness
2.
Introduce basic information that must be
understood for the application
3.
Provide assessment that basic information is
understood.
Typically 10 multiple choice questions (15
minutes). Our students take the IRAT online
with the benefit of immediate instructor item
analysis.
Scantrons work well, but item analysis not
immediately available.
GRAT
•
•
•
•
Students take the IRAT as a team.
This exercise is usually fairly easy for the
class. (15 minutes).
Good opportunity to use IF AT cards. Teams
answer all of the questions at one time.
Discussion focuses only on questions that
were difficult as assessed by item analysis of
IRAT scores and a scan of IF -AT cards.
(http://www.epsteineducation.com/home/orde
r/default.aspx )
Components
Sequence of Learning
R. Levine
The “Four S’s” of
•
•
•
•
*
TBL
Significant problem
Same Problem
Single Best Answer
– Teams must discuss the choices and arrive at a
consensus best answer. (Generates good intrateam teaching and discussion.)
Simultaneous reporting
– All teams report their answer at the same time.
Lettered cards can be used or Audience response
systems can be used. A team member must then
justify their team’s answer. Robust inter-team
discussions often follow when teams have
selected different answers.
Application




Questions must be challenging, but there
should be a clear best answer.
Question should generate good team
discussion.
The application must be perceived as
productive. Students should feel that the
exercise helped them learn the material.
Teams are allowed to challenge questions, but
they must document the reasons for their
challenge and/or re-write the question to
make it better.
Example Application Muliple Choice
Question: Muscle Physiology
The two finalists in the world arm-wrestling
championships at Petaluma, California, are well-matched.
Upper body muscle mass, insensitivity to pain, motivation,
and experience are identical between the two. Vito, a Las
Vegas bookie, slips you the results of each competitor’s
physical exam and ‘asks’ you to predict the winner. What
is most likely to determine the eventual winner?
A.
B.
C.
D.
E.
Maximum cardiac output
Mitochondrial content of the exercising muscles
Muscle glycogen content
Oxygen carrying capacity of the blood
Phosphocreatine levels in the muscles
Example Application Short
Answer Question:
A patient with the following
symptoms has been admitted to
ER. What imaging test would you
order first?
Write your response on the
whiteboard
Example Application Gallery
Walk Question:
A 16 year old girl named Jane has come to your office for counseling following a
positive pregnancy test. She informs you that her maternal grandfather has a
bleeding disorder and regularly has been injected with a protein called Factor
VIII. Jane has 2 younger brothers that are in good health. Jane’s mother Judy is
39 years old and is also 3 months pregnant. Jane’s father Al is 60 years old and
is in excellent health. Jane confides in you that the father of the baby is her first
cousin Bill, who is 26 years old and talked her into a sexual liaison when she was
“a little tipsy” from wine that was provided by Bill.
List and describe all of the genetic and ethical issues that should be discussed
during the counseling session. Place your teams answers on the easel paper
provided. All teams post their answers at the same time.
Then, have each team choose the response that they think is best (not including
their own). (Simultaneously displayed.)
Teams describe and defend their own answer as well as defend their choice for
the best response.
Peer Evaluation in Team Based
Learning
Peer evaluation is an important component of TBL, helping
to assure that students are accountable to each other.
Regular TBL exercises provide an excellent basis for
students to practice, refine, and assess their peers on basic
competencies: communication, life-long learning, self
awareness, ethical and moral reasoning, problem solving,
and professionalism.
With some training and an appropriate peer evaluation
instrument, students can obtain quality feedback from their
peers on the degree to which they are mastering these
competencies. This can be a significant added bonus of
using TBL.
Students Like It!
Scores represent experience with TBLs in Biochemistry at IUSM-SB
Comparison of Psychiatry and
Ob/Gyn NBME Performance
Psych began TBL
in Class of 2004
NBME percentile score
1
0.8
Ob/gyn began TBL
in Class of 2006
72nd
66th 69th
58th
60th
52nd
0.6
0.4
49th
50th
42nd 42nd 46th
35th
0.2
0
2003
2004
2005
2006
2007
2008
2008 scores represent 1st half of the year
Resources
 Team-Based Learning: A Transformative Use of Small
Groups (2002)
 L. K. Michaelsen, A. B. Knight, and L. D. Fink, Pareger
Publishing, Westport, Ct.
 Team-Based Learning for Health Professions Education

Michaelsen, et. al 2008, Stylus Publishing, Sterling VA
 Team Based Learning Collaborative
 http://www.teambasedlearning.org
• MedEdPortal
https://www.mededportal.org//
• Twelve Tips for doing effective Team-Base Learning (2010)
•
D. Parmelee and L. Michaelsen Medical Teacher 32:118-122.